Both before and after the Centers for Medicare and Medicaid Services’ (CMS) policy reversal on work requirements, stakeholders have debated whether employment leads to improved health outcomes. CMS and states that have implemented or are trying to implement work requirements argue they do, while others disagree. The recent research of the Kaiser Family Foundation (KFF), a nonpartisan organization, illuminates what the data says on the relationship between work and health. This piece provides a recap of KFF’s findings.
Effect of health and health coverage on work – research unsurprisingly found that being in poor health is associated with an increased risk of job loss or unemployment.
- Individual characteristics such as income, race, sex or education level may mediate the relationship between poor health and employment.
- In addition, research suggests access to affordable health insurance and care promotes individuals’ ability to obtain and maintain employment.
- In an analysis of Medicaid expansion in Michigan, 69% of enrollees said they performed better at work once they got coverage, and 55% of enrollees who were out of work said the coverage made them better able to look for a job.
Effect of work on health and health coverage – inconclusive overall. Some studies show a positive effect of work on health while others show no relationship or isolated effects.
- In addition, research shows an association between unemployment and poor health outcomes, but researchers caution that these findings do not necessarily support an opposite relationship: employment causes improved health.
- The quality and stability of work is a key factor in the work-health relationship: research finds that low-quality, unstable, or poorly paid jobs lead to or are associated with adverse effects on health.
- The work-health association could reflect people in good health being more likely to work rather than work causing good health. This is an output of the “healthy worker effect”: healthy individuals are more likely to enter the workforce whereas those with health problems are at increased risk to withdraw from and remain outside the workforce.
- Authors of a report showing a positive effect of work on health note caveats to drawing broad conclusions about work and health:
- 1) Findings are about average or group affects, and a minority of people may experience contrary health effects from work
- 2) The beneficial health effects of work depend on the nature and quality of work
- 3) The social context must be considered, particularly social gradients in health and regional deprivation
- While work can help people access employer-sponsored health coverage, many jobs—especially low-wage jobs—do not come with an affordable offer of employer coverage.
Effect of volunteerism on health – there is limited evidence that volunteer activities affects health outcomes.
- One literature review on the health effects of volunteering “did not find any consistent, significant health benefits arising through volunteering” based on experimental studies available at the time of the literature review.
- Another study that examined the health benefits of truly altruistic volunteering versus volunteering focused on seeking benefits. While the authors found beneficial effects of both forms of volunteering on health, altruistic volunteering had significantly stronger effects on health. This may indicate that health benefits of volunteering are likely to be weaker when individuals are compelled to engage in volunteering.
These findings have several limitations and implications when applying them to Medicaid eligibility work requirements:
- Since the link between work and health is not universal across populations or social contexts, effects found for the general population may not apply to the low-income Medicaid population, who report worst health status compared to the total U.S. population and often face more significant challenges related to housing, food security, and other social determinants of health.
- Work or volunteering undertaken to fulfill a requirement may produce different health effects than work or volunteer activities studied in existing literature.
- Research on health effects of work requirements in Temporary Assistance for Needy Families (TANF) suggests that they did not benefit and sometimes negatively affected health among enrollees and their dependents.
- Another literature review on work and health found that forcing claimants off benefits and into work without adequate supports would more likely harm than improve their health.
- Limited job availability, low demand for labor, or poor job quality may moderate any positive health effects of employment.
- Most studies in the field do not adjust for quality of employment and include all kinds of jobs in their analysis despite the possibility that different forms of employment have different health effects.
- Long-term effects of work on health are unclear.
- Much of the evidence on the work/health relationship is about short-term effects after about one year.
- Loss of health insurance due to not meeting reporting or work requirements under waivers could affect access to health care and health.
- Work requirements in Medicaid could lead to large Medicaid coverage losses, especially among people who would remain eligible for the program but lose coverage due to administrative burdens or red tape versus those who would lose eligibility due to not working.
- A study evaluating welfare-to-work interventions found that some programs led to a reduction in health insurance coverage for both children and parents.
- Policies that have disproportionate effects on certain Medicaid enrollees could widen health disparities.
- If racial minority groups, people with disabilities, or other vulnerable populations face similarly disproportionate challenges in meeting work requirements when they are attached to the Medicaid program, these policies could result in wider disparities in health insurance coverage and health outcomes.
Overall, the research indicates work requirements for Medicaid eligibility may not necessarily benefit health, with some research suggesting such policies could negatively affect health. Due to the difficulty of controlling for health selection bias and the inability to conduct randomized controlled trials, one cannot determine a causal relationship between employment and good health, though there is evidence of a correlation between employment and good health. Factors such as such job availability, job quality and social context, however, mediate the effect of work or work requirements on health. Work requirement policies could lead to emotional strain, loss of health coverage or widening of health disparities for vulnerable populations, given the population of the Medicaid population.
As a result of litigation challenging work requirements, Arkansas, Kentucky and New Hampshire have had state Medicaid waiver proposals that would impose work requirements in Medicaid set aside by the courts. As of July 2019, Indiana is the only other state to have implemented a work requirement waiver. Five more states have approved waivers that are not yet implemented, and another seven states have waiver requests pending with CMS.
Given the active debate in courts on legality of work requirements, the question of whether work requirements will promote health will remain key. It is important that policymakers not extrapolate the findings from the research to arrive at unsupported conclusions about the Medicaid population. As the evidence thus far has been inconclusive, further research is necessary.